Mammography Patient Screening

Yes
No
Have you had a prior mammogram?
Are you having any breast problems?


Lump Left Right
Discharge Left Right
Pain Left Right
Skin Changes Left Right
Other Left Right
Is your appointment today the result of these problems?
Have you had breast cancer?
Has any blood relative had breast cancer BEFORE age 50?


Mother
Sister
Daughter
Other
Have you had breast surgery?


Cyst Aspiration
Needle Biopsy
Surgical Biopsy
Lumpectomy (for cancer)
Mastectomy
Radiation Therapy
Implants
Reduction
Are you presently taking hormone replacement?
Are you pregnant?
Are you breastfeeding?

Please check all of the following that are true for you:

I do not know my personal breast cancer history
I have had endometrial cancer
I have had ovarian cancer
I have the BRCA 1 gene mutation
I have the BRCA 2 gene mutation
A family member has had ovarian cancer
I have been through menopause
I have never had children
I had my first child after age 30
I have had previous chest radiation therapy
I have had a previous breast biopsy that showed a high risk lesion